Two-Year Outcomes After Conventional or Endovascular Repair of Abdominal Aortic Aneurysms

Abstract

Two randomized trials have shown better outcomes with elective endovascular repair of abdominal aortic aneurysms than with conventional open repair in the first month after the procedure. We investigated whether this advantage is sustained beyond the perioperative period. methods We conducted a multicenter, randomized trial comparing open repair with endovascular repair in 351 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable candidates for both techniques. Survival after randomization was calculated with the use of Kaplan-Meier analysis and compared with the use of the log-rank test on an intention-to-treat-basis. results Two years after randomization, the cumulative survival rates were 89.6 percent for open repair and 89.7 percent for endovascular repair (difference, ¡0.1 percentage point; 95 percent confidence interval, ¡6.8 to 6.7 percentage points). The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair (difference, 3.7 percentage points; 95 percent confidence interval, ¡0.5 to 7.9 percentage points). This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. The rate of survival free of moderate or severe complications was also similar in the two groups at two years (at 65.9 percent for open repair and 65.6 percent for endovascular repair; difference, 0.3 percentage point; 95 percent confidence interval, ¡10.0 to 10.6 percentage points). conclusions The perioperative survival advantage with endovascular repair as compared with open repair is not sustained after the first postoperative year.

A Cost-Effectiveness Model Comparing Endovascular Repair to Open Surgical Repair of Abdominal Aortic Aneurysms in Canada

“…The model assumed the annual probability of endoleaks to be 2.6%, and the probability of conversion from EVAR to OR to be 0.66%. Although the DREAM study [23] found the mean utility for OR to be slightly higher than EVAR (0.72 vs. 0.71), no utility decrement was applied. In sensitivity analysis, OR was assumed to have 0.01 higher utility than EVAR during the long‐term phase of the model.…”

“…Survival beyond 1 year was reported in both the EVAR‐1 [3] and the DREAM [23] trials. Both trials found that cumulative all‐cause mortality for EVAR and OR converged after approximately 2 years.…”

Pre‐operative coronary revascularization: an optimal therapy for high‐risk vascular surgery patients?

“…Our approach to peri‐operative cardiac risk assessment and management of patients in need of vascular surgery has substantially improved in the past few decades as a result of the findings of observational studies and clinical trials (12,13,20,22,45) as well as the recent introduction of endovascular repair, which is associated with a considerable reduction of myocardial stress (46) with subsequent reduction in post‐operative cardiac morbidity (47). These studies confirmed the concept that patients at increased risk of peri‐operative cardiac events can be identified on the basis of clinical markers of increased cardiac risk.…”

Follow-up after endovascular aortic aneurysm repair can be stratified based on first postoperative imaging

“…Although EVAR has a clear short‐term survival benefit compared with open repair, the risk of graft failure mandates regular follow‐up to allow timely identification and management of complications. Annual rupture rates of 0·7–1·4 per cent and annual reintervention rates of 4–18 per cent have been identified in various studies. Current guidelines recommend annual imaging surveillance, whereas surveillance programmes vary significantly among institutions in frequency and imaging modality used.…”